Testicular cancer

Etoposide is indicated in combination with other approved chemotherapeutic agents for the treatment of first line, recurrent or refractory testicular cancer in adults.

Small cell lung cancer

Etoposide is indicated in combination with other approved chemotherapeutic agents for the treatment of small cell lung cancer in adults.

Hodgkin's lymphoma

Etoposide is indicated in combination with other approved chemotherapeutic agents for the treatment of Hodgkin's lymphoma in adult and paediatric patients.

Non-Hodgkin's lymphoma

Etoposide is indicated in combination with other approved chemotherapeutic agents for the treatment of non-Hodgkin's lymphoma in adult and paediatric patients.

Acute myeloid leukaemia

Etoposide is indicated in combination with other approved chemotherapeutic agents for the treatment of acute myeloid leukaemia in adult and paediatric patients.

Gestational trophoblastic neoplasia

Etoposide is indicated for first line and second line therapy in combination with other approved chemotherapeutic agents for the treatment of high risk gestational trophoblastic neoplasia in adults.

Ovarian cancer

Etoposide is indicated in combination with other approved chemotherapeutic agents for the treatment of non-epithelial ovarian cancer in adults.

Etoposide is indicated for the treatment of platinum-resistant/refractory epithelial ovarian cancer in adults.

Etoposide should only be administered and monitored under the supervision of a qualified physician experienced in the use of anti-neoplastic medicinal products (see section 4.4).

Posology

Adult population

The recommended dose of etoposide in adult patients is 50 to 100 mg/m²/day on days 1 to 5 or 100 to 120 mg/m² on days 1, 3, and 5 every 3 to 4 weeks in combination with other drugs indicated in the disease to be treated. Dosage should be modified to take into account the myelosuppressive effects of other drugs in the combination or the effects of prior radiotherapy or chemotherapy (see section 4.4) which may have compromised bone marrow reserve. The doses after the initial dose should be adjusted if neutrophil count is below 500 cells/mm³ for more than 5 days. In addition the dose should be adjusted in case of occurrence of fever, infections, or at a thrombocyte count below 25,000 cells/mm³, which is not caused by the disease. Follow up doses should be adjusted in case of occurrence of grade 3 or 4 toxicities or if renal creatinine clearance is below 50 ml/min. At decreased creatinine clearance of 15 to 50 ml/min a dose reduction by 25% is recommended.

Administration Precautions: As with other potentially toxic compounds, caution should be exercised in handling and preparing the solution of etoposide. Skin reactions associated with accidental exposure to etoposide may occur. The use of gloves is recommended. If etoposide solution contacts the skin or mucosa, immediately wash the skin with soap and water and flush the mucosa with water (see section 6.6).

Elderly population

No dosage adjustment is necessary in elderly patients (age > 65 years old), other than based on renal function (see section 5.2).

Paediatric population

Hodgkin's lymphoma; non-Hodgkin's lymphoma; acute myeloid leukaemia

Etoposide in paediatric patients has been used in the range of 75 to 150 mg/m²/day for 2 to 5 days in combination with other antineoplastic agents. The treatment regimen should be chosen according to the local standard of care.

Ovarian cancer; small cell lung cancer; gestational trophoblastic neoplasia; testicular cancer

The safety and efficacy of etoposide below 18 years of age have not been established. Currently available data are described in section 5.2 but no recommendation on a posology can be made.

Renal impairment

In patients with impaired renal function, the following initial dose modification should be considered based on measured creatinine clearance.

In patients with creatinine clearance less than 15 ml/min and on dialysis further dose reduction is likely to be required as etoposide clearance is further reduced in these patients (see section 4.4). Subsequent dosing in moderate and severe renal impairment should be based on patient tolerance and clinical effect (see section 4.4). Since etoposide and its metabolites are not dialyzable, it can be administered pre- and post-haemodialysis (see section 4.9).

Method of administration

Etoposide is administered by slow intravenous infusion (usually over a 30 to 60 minute period) (see section 4.4).

For instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6.

• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

• Concomitant use of yellow fever vaccine or other live vaccines is contraindicated in immunosuppressed patients (see section 4.5).

• Lactation (see section 4.6).

Etoposide should only be administered under the supervision of a qualified physician experienced in the use of anti-neoplastic medicinal products. In all instances where the use of etoposide is considered for chemotherapy, the physician must evaluate the need and usefulness of the medicinal product against the risk of adverse reactions. Most such adverse reactions are reversible if detected early. If severe reactions occur, the medicinal product should be reduced in dose or discontinued and appropriate corrective measures should be taken according to the clinical judgment of the physician. Reinstitution of etoposide therapy should be carried out with caution, and with adequate consideration of the further need for the medicinal product and close attention to possible recurrence of toxicity.

Myelosuppression

Dose-limiting bone marrow suppression is the most significant toxicity associated with etoposide therapy. Fatal myelosuppression has been reported following etoposide administration. Patients being treated with etoposide must be observed for myelosuppression carefully and frequently both during and after therapy.

The following haematological parameters should be measured at the start of therapy and prior to each subsequent dose of etoposide: platelet count, haemoglobin, white blood cell count and differential. If radiotherapy or chemotherapy has been given prior to starting etoposide treatment, an adequate interval should be allowed to enable the bone marrow to recover. Etoposide should not be administered to patients with neutrophil counts below 1,500 cells/mm³ or platelet counts below 100,000 cells/mm³, unless caused by malignant disease.

Doses subsequent to the initial dose should be adjusted if neutrophil count below 500 cells/mm³ occurs for more than 5 days or is associated with fever or infection, if platelet count below 25,000 cells/mm³ occurs, if any other grade 3 or 4 toxicity develops or if renal clearance is less than 50 ml/min.

Severe myelosuppression with resulting infection or haemorrhage may occur. Bacterial infections should be brought under control before treatment with etoposide.

Secondary leukaemia

The occurrence of acute leukaemia, which can occur with or without myelodysplastic syndrome, has been described in patients that were treated with etoposide-containing chemotherapeutic regimens.

Neither the cumulative risk, nor the predisposing factors related to the development of secondary leukaemia are known. The roles of both administration schedules and cumulative doses of etoposide have been suggested, but have not been clearly defined.

An 11q23 chromosome abnormality has been observed in some cases of secondary leukaemia in patients who have received epipodophyllotoxins. This abnormality has also been seen in patients developing secondary leukaemia after being treated with chemotherapy regimens not containing epipodophyllotoxins and in leukaemia occurring de novo. Another characteristic that has been associated with secondary leukaemia in patients who have received epipodophyllotoxins appears to be a short latency period, with average median time to development of leukaemia being approximately 32 months.

Hypersensitivity

Physicians should be aware of the possible occurrence of an anaphylactic reaction with etoposide, manifested by chills, fever, tachycardia, bronchospasm, dyspnoea and hypotension, which can be fatal. Treatment is symptomatic. Etoposide should be terminated immediately, followed by the administration of pressor agents, corticosteroids, antihistamines, or volume expanders at the discretion of the physician. An increased risk for infusion-related hypersensitivity reactions was observed when in-line filters were used during etoposide administration. In-line filters should not be used.

Hypotension

Etoposide should be given only by slow intravenous infusion (usually over a 30 to 60 minute period) since hypotension has been reported as a possible side effect of rapid intravenous injection.

Injection site reaction

Injection site reactions may occur during the administration of etoposide. Given the possibility of extravasation, it is recommended to closely monitor the infusion site for possible infiltration during administration of the medicinal product.

Low serum albumin

Low serum albumin is associated with increased exposure to etoposide. Therefore patients with low serum albumin may be at increased risk for etoposide-associated toxicities.

Impaired renal function

In patients with moderate (CrCl = 15 to 50 ml/min), or severe (CrCl < 15 ml/min) renal impairment undergoing haemodialysis, etoposide should be administered at a reduced dose (see section 4.2). Haematological parameters should be measured and dose adjustments in subsequent cycles considered based on haematological toxicity and clinical effect in patients with moderate and severe renal impairment.

Impaired hepatic function

Patients with impaired hepatic function should regularly have their hepatic function monitored due to the risk of accumulation.

Tumour lysis syndrome

Tumour lysis syndrome (sometimes fatal) has been reported following the use of etoposide in association with other chemotherapeutic medicinal products. Close monitoring of patients is needed to detect early signs of tumour lysis syndrome, especially in patients with risk factors such as bulky treatment-sensitive tumours and renal insufficiency. Appropriate preventive measures should also be considered in patients at risk of this complication of therapy.

Mutagenic potential

Given the mutagenic potential of etoposide, an effective method of contraception is required for both male and female patients during treatment and up to 6 months after ending treatment. Genetic consultation is recommended if the patient wishes to have children after ending the treatment. As etoposide may decrease male fertility, preservation of sperm may be considered for the purpose of later fatherhood (see section 4.6).

Paediatric population

The clinician should be aware that Etoposide contains ethanol and polysorbate 80 as excipients.

Excipients

This medicinal product contains 33 vol % ethanol (alcohol), i.e. 262 mg per ml. With a dose of 120 mg/m², 2.7 g ethanol is applied to a patient with a body surface of 1.73 m², equivalent to 68 ml beer, 28 ml wine per dose. Harmful for those suffering from alcoholism. To be taken into account in pregnant or breastfeeding women, children and high-risk groups such as patients with liver disease, or epilepsy.

Consideration should be given to possible effects on the central nervous system.

The amount of alcohol in this medicinal product may alter the effects of other medicinal products.

The amount of alcohol in this medicinal product may impair the patient's ability to drive or use machines (see section 4.7).

Etoposide injection contains polysorbate 80. In premature infants a life threatening syndrome of liver and renal failure, pulmonary deterioration, thrombocytopenia and ascites has been associated with an injectable vitamin E product containing polysorbate 80.

Effects of other medicinal products on the pharmacokinetics of etoposide

High-dose cyclosporine, resulting in concentrations above 2000 ng/ml, administered with oral etoposide has led to an 80 % increase in etoposide exposure (AUC) with a 38 % decrease in total body clearance of etoposide compared to etoposide alone.

Concomitant cisplatin therapy is associated with reduced etoposide clearance.

Concomitant phenytoin therapy is associated with increased etoposide clearance and reduced efficacy, and other enzyme-inducing antiepileptic therapy may be associated with increased etoposide clearance and reduced efficacy.

In vitro plasma protein binding is 97 %. Phenylbutazone, sodium salicylate and acetylsalicylic acid may displace etoposide from plasma protein binding.

Effect of etoposide on the pharmacokinetics of other medicinal products

Co-administration of antiepileptic medicinal products and etoposide can lead to decreased seizure control due to pharmacokinetic interactions between the medicinal products.

Co-administration of warfarin and etoposide may result in elevated international normalized ratio (INR). Close monitoring of INR is recommended.

Pharmacodynamic interactions

There is increased risk of fatal systemic vaccinal disease with the use of yellow fever vaccine. Live vaccines are contraindicated in immunosuppressed patients (see section 4.3).

Prior or concurrent use of other medicinal products with similar myelosuppressant action as etoposide may be expected to have additive or synergetic effects (see section 4.4).

Cross-resistance between anthracyclines and etoposide has been reported in preclinical experiments.

Paediatric population

Interaction studies have only been performed in adults.

Women of childbearing potential/Contraception in males and females

Women of childbearing potential should use appropriate contraceptive measures to avoid pregnancy during etoposide therapy. Etoposide has been shown to be teratogenic in mice and rats (see section 5.3). Given the mutagenic potential of etoposide, an effective method of contraception is required for both male and female patients during treatment and up to 6 months after treatment (see section 4.4). Genetic consultation is recommended if the patient wishes to have children after ending the treatment.

Pregnancy

There are no or limited amount of data from the use of etoposide in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). In general etoposide can cause foetal harm when administered to pregnant women. Etoposide should not be used during pregnancy unless the clinical condition of the woman requires treatment with etoposide.

Women of childbearing potential should be advised to avoid becoming pregnant. Women of childbearing potential have to use effective contraception during and up to 6 months after treatment. If this medicinal product is used during pregnancy, or if the patient becomes pregnant while receiving this medicinal product, the patient should be informed of the potential hazard to the fetus.

Breast-feeding

Etoposide is excreted in human milk. There is the potential for serious adverse reactions in nursing infants from etoposide. Therefore, etoposide is contraindicated during breast-feeding (see section 4.3). A decision must be made whether to discontinue breast-feeding or to discontinue etoposide taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.

Fertility

As etoposide may decrease male fertility, preservation of sperm may be considered for the purpose of later fatherhood.

No studies on the effects on the ability to drive and use machines have been performed with etoposide. The amount of ethanol in Etoposide may impair the ability to drive or use machines (see section 4.4) after a course of treatment. In general, etoposide may cause adverse reactions that affect the ability to drive or use machines such as fatigue, somnolence, nausea, vomiting, cortical blindness, hypersensitivity reactions with hypotension. Patients who experience such adverse reactions should be advised to avoid driving or using machines.

Summary of the safety profile

Dose-limiting bone marrow suppression is the most significant toxicity associated with etoposide therapy. In clinical studies in which etoposide was administered as a single agent at a total dose of ≥ 450 mg/m² the most frequent adverse reactions of any severity were leukopenia (91%), neutropenia (88%), anaemia (72%) thrombocytopenia (23%), asthenia (39%), nausea and/or vomiting (37%), alopecia (33%) and chills and/or fever (24%).

The table below lists adverse events presented by system organ class and frequency, which is defined by the following categories: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), not known (cannot be estimated from the available data).

Description of selected adverse reactions

In the paragraphs below the incidences of adverse events, given as the mean percent, are derived from studies that utilised single -agent etoposide therapy.

Haematological toxicity

Myelosuppression (see section 4.4.) with fatal outcome has been reported following administration of etoposide. Myelosuppression is most often dose-limiting. Bone marrow recovery is usually complete by day 20, and no cumulative toxicity has been reported.

Granulocyte and platelet nadirs tend to occur about 10 – 14 days after administration of etoposide depending on the way of administration and treatment scheme. Nadirs tend to occur earlier with intravenous administration compared to oral administration.

Leukopenia and severe leukopenia (less than 1,000 cells/mm³) were observed in 91 % and 17 %, respectively, for etoposide. Thrombocytopenia and severe thrombocytopenia (less than 50,000 platelets/mm³) were seen in 23% and 9 %, respectively, for etoposide. Reports of fever and infection were also very common in patients with neutropenia treated with etoposide. Bleeding has been reported.

Gastrointestinal toxicity

Nausea and vomiting are the major gastrointestinal toxicities of etoposide. Nausea and vomiting can usually be controlled by antiemetic therapy.

Alopecia

Reversible alopecia, sometimes progressing to total baldness, has been observed in up to 44 % of patients treated with etoposide.

Blood pressure changes

Hypotension

Transient hypotension following rapid intravenous administration has been reported in patients treated with etoposide and has not been associated with cardiac toxicity or electrocardiographic changes. Hypotension usually responds to cessation of infusion of etoposide and/or other supportive therapy as appropriate. When restarting the infusion, a slower administration rate should be used.

No delayed hypotension has been noted.

Hypertension

In clinical studies involving etoposide, episodes of hypertension have been reported. If clinically significant hypertension occurs in patients receiving etoposide, appropriate supportive therapy should be initiated.

Hypersensitivity

Anaphylactic-type reactions have also been reported to occur during or immediately after intravenous administration of etoposide. The role the concentration or rate of infusion plays in the development of anaphylactic-type reactions is uncertain. Blood pressure usually normalises within a few hours after cessation of the infusion. Anaphylactic-type reactions can occur with the initial dose of etoposide.

Anaphylactic reactions (see section 4.4), manifested by chills, tachycardia, bronchospasm, dyspnoea, diaphoresis, pyrexia, pruritus, hypertension or hypotension, syncope, nausea, and vomiting have been reported to occur in 3% (7 of 245 patients treated with etoposide in 7 clinical studies) of patients treated with etoposide. Facial flushing was reported in 2% of patients and skin rashes in 3%. These reactions have usually responded promptly to the cessation of the infusion and administration of pressor agents, corticosteroids, antihistamines, or volume expanders as appropriate.

Acute fatal reactions associated with bronchospasm have been reported with etoposide. Apnoea with spontaneous resumption of breathing after discontinuation of etoposide treatment has been reported.

Metabolic complications

Tumour lysis syndrome (sometimes fatal) has been reported following the use of etoposide in association with other chemotherapeutic agents (see section 4.4).

Paediatric population

The safety profile of paediatric patients and adults is expected to be similar.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Total doses of 2.4 – 3.5 g/m² etoposide, administered intravenously over three days, have resulted in severe mucositis and myelotoxicity. Metabolic acidosis and cases of serious hepatic toxicity have been reported in patients receiving higher than recommended intravenous doses of etoposide. Similar toxicities can be expected with oral formulation.

A specific antidote is not available. Treatment should therefore be symptomatic and supportive, and patients should be closely monitored.

Etoposide and its metabolites are not dialysable.

Pharmacotherapeutic group: Cytostatics, plant alkaloids and other natural products, podophyllotoxin derivatives, ATC code: L01CB01

Mechanism of action

The main effect of etoposide appears to be at the late S and early G₂ portion of the cell cycle in mammalian cells. Two dose-dependent responses are seen: At high concentrations (10 mcg/ml or more), cells entering mitosis are lysed; at low concentrations (0.3 to 10 mcg/ml), cells are inhibited from entering prophase. Microtubule assembly is not affected. The predominant macromolecular effect of etoposide seems to be the rupture of the double strand by an interaction with DNA-topoisomerase II or by the formation of free radicals. Etoposide has been shown to cause metaphase arrest in chick fibroblasts.

Absorption

After intravenous infusion, the maximum plasma concentration (C_max) and area under the plasma concentration vs. time curve (AUC) values exhibit marked intra- and inter-subject variability.

Distribution

The mean volumes of distribution at steady state range from 18 to 29 liters. Etoposide shows low penetration into the cerebrospinal fluid (CSF). In vitro, etoposide is highly protein bound (97%) to human plasma proteins.

Etoposide binding ratio correlates directly with serum albumin in cancer patients and normal volunteers (see section 4.4). Unbound fraction of etoposide correlates significantly with bilirubin in cancer patients.

Biotransformation

The hydroxyacid metabolite [4' dimethyl-epipodophyllic acid-9-(4,6 0-ethylidene-β -D-glucopyranoside)], formed by opening of the lactone ring, is found in the urine of adults and children. It is also present in human plasma, presumably as the trans isomer. Glucuronide and/or sulfate conjugates of etoposide are also excreted in human urine. In addition, O-demethylation of the dimethoxyphenol ring occurs through the CYP450 3A4 isoenzyme pathway to produce the corresponding catechol.

Elimination

On intravenous administration, the disposition of etoposide is best described as a biphasic process with a distribution half-life of about 1.5 hours and a terminal elimination ranging from 4 to 11 hours.

Total body clearance values range from 33 to 48 ml/min or 16 to 36 ml/min/m² and, like the terminal elimination half-life, are independent of dose over a range 100 to 600 mg/m². After intravenous administration of ¹⁴C etoposide (100 to 124 mg/m²), mean recovery of radioactivity in the urine was 56% (45% of the dose was excreted as etoposide) and faecal recovery of radioactivity was 44% of the administered dose at 120 hours.

Linearity/non-linearity

Total body clearance and the terminal elimination half-life are independent of dose over a range 100 to 600 mg/m². Over the same dose range, the AUC and the C_max values increase linearly with dose.

Renal impairment

Patients with impaired renal function receiving etoposide have exhibited reduced total body clearance, increased AUC and higher steady state volume of distribution (see section 4.2).

Hepatic impairment

In adult cancer patients with liver dysfunction, total body clearance of etoposide is not reduced.

Elderly population

Although minor differences in pharmacokinetic parameters between patients ≤ 65 years and > 65 years of age have been observed, these are not considered clinically significant.

Paediatric population

In children, approximately 55% of the dose is excreted in the urine as etoposide in 24 hours. The mean renal clearance of etoposide is 7 to 10 ml/min/m² or about 35% of the total body clearance over a dose range of 80 to 600 mg/m². Etoposide, therefore, is cleared by both renal and nonrenal processes, i.e. metabolism and biliary excretion. The effect of renal disease on plasma etoposide clearance is not known in children. In children, elevated SGPT levels are associated with reduced drug total body clearance. Prior use of cisplatin may also result in a decrease of etoposide total body clearance in children.

An inverse relationship between plasma albumin levels and etoposide renal clearance is found in children.

Gender

Although minor differences in pharmacokinetic parameters between genders have been observed, these are not considered clinically significant.

Drug interactions

In a study of the effects of other therapeutic agents on in vitro binding of ¹⁴C etoposide to human serum proteins, only phenylbutazone, sodium salicylate, and aspirin displaced protein-bound etoposide at concentrations generally achieved in vivo (see section 4.5).

Chronic toxicity

Anaemia, leukopenia, and thrombocytopenia were observed in rats and mice, while dogs had mild reversible deterioration of liver and kidney functions. The dose multiple (based on mg/m² doses) for these findings at the no-observed adverse-effect-level in the preclinical studies were ≥ approximately 0.05 times compared to the highest clinical dose. Historically, preclinical species have been more sensitive compared to humans towards cytotoxic agents. Testicular atrophy, spermatogenesis arrest, and growth retardation were reported in rats and mice.

Mutagenicity

Etoposide is mutagenic in mammalian cells.

Reproductive toxicity

In animal studies etoposide was associated with dose-related embryotoxicity and teratogenicity.

Carcinogenic potential

Given its mechanism of action, etoposide should be considered a possible carcinogen in humans.

Citric acid (anhydrous) (E330)

Polysorbate 80

Macrogol 300

Ethanol

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

Plastic devices made of acrylic or ABS polymers have been reported to crack when used with undiluted Etoposide 20 mg/ml, concentrate for solution for infusion. This effect has not been reported with etoposide after dilution of the concentrate for solution for infusion according to instructions.

Unopened vial: 2 years.

Once opened, the product is chemically and microbiologically stable for five days.

The physical and chemical in-use stability of the diluted product (0.2 mg/ml and 0.4 mg/ml) has been demonstrated for 24 hours at 20 ° C to 25 ° C.

From a microbiological point of view, unless the method of dilution precludes the risk of microbial contamination, the diluted product should be used immediately.

If not used immediately, in-use storage times and conditions are the responsibility of the user.

When the diluted product is stored in PVC bags a leaching of plasticizer in the product or precipitation may occur. Therefore, it is recommended to use glass containers for the diluted product.

Do not refrigerate or freeze.

For storage conditions after dilution of the medicinal product, see section 6.3.

Clear glass (type I) vial with bromobutyl rubber, window style stopper and with flip-off aluminium caps.

Pack of 1 vial with 5 ml.

Pack of 1 vial with 25 ml.

Not all pack sizes may be marketed.

Handle according to guidelines for cytotoxics.

Concentrate for solution for infusion must not be used undiluted.

Etoposide should not be mixed with other medicinal products.

Etoposide should be stored out of the sight and reach of children.

Etoposide should only be diluted with sodium chloride 9 mg/ml (0.9 %) solution for injection or 5 % glucose solution. The concentration of etoposide in the reconstituted solution for infusion should not exceed 0.4 mg/ml due to the risk of precipitation.

As with other potentially cytotoxic compounds caution should be exercised when handling etoposide (gloves, mask, overall). Contact with skin or mucosa should be avoided.

Skin reactions associated with accidental exposure to etoposide may occur. If etoposide comes into contact with skin or mucosa, immediately wash the skin or mucosa thoroughly with soap and water.

Only for intravenous use.

Unused solution should be discarded.

Syringes, containers, absorbent materials, solution and any other contaminated material should be placed in a designated impervious container and incinerated, in accordance with local procedures.

Only clear solutions practically free from particles should be used.

Cytotoxics should not be handled by pregnant personnel.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.